IMPORTANT! Please, fill in all fields prior to sending the notification!

Action of the Insured in case of occurrence of an insurance event

Upon occurrence of an insured event the Insured shall immediately notify Colonnade Insurance S.A. – Bulgaria Branch in writing by filling in the notification below and sending it directly to Colonnade Insurance S.A. – Bulgaria Branch via:

- E - mail:

- Address:1113 Sofia, Iztok, 3B Nikolay Haytov str., Building 7, floor 4

“Claims Department” of Colonnade Insurance S.A. – Bulgaria Branch

- Tel:+ 359 2 930 93 30

If the insured event occurs on weekend or any official national holiday, the notification may be sent on the first working day afterwards. The indemnity payment will be made within 15 days after receiving all of the required documents.

NOTIFICATION
Insured: / Personal ID number:
Address:
E-mail:
Phone number: / Mobile:
Policy number:
Place of work:
Occupation:
Date of occurrence:
Description of the insurance event:
Consequences (injury description due to the accident):
Medical treatment performed (short description, name of treating physician):
Attached documents:
Required indemnity in BGN:
Bank account in BGN for indemnity payment:
BIC: / IBAN:
Beneficiary:
Personal Data Agreement
By providing personal information to Colonnade Insurance S.A. - Bulgaria Branch (“Colonnade”) (the Insurer) in connection with your statement to the attention of the Insurer and signing below you explicitly consent the Insurer to collect the personal data provided hereby and to process them in the way and for the purposes set out in the Privacy Policy published on and for the purposes of the insurance legal relation and the direct marketing, by conducting with those personal data (or sets of personal data enclosing the personal data provided hereby) any operation or set of operations, whether or not by automated means, consisting upon the Insurer's discretion of collection, recording, organisation, structuring, storage, adaptation or alteration, retrieval, consultation, use, disclosure by transmission, dissemination or otherwise making available, alignment or combination, restriction, erasure or destruction of personal data. Furthermore, you explicitly consent, in connection to the processing purposes specified above, the personal data provided hereby to be disclosed and/or transferred to other countries, if needed. You can also request a copy of the Privacy Notice by sending email at: or by writing to: Colonnade Insurance S.A. - Bulgaria Branch, Iztok, 3B Nikolay Haytov Street, Building 7, Floor 4, 1113 Sofia, Bulgaria.
You also agree hereby that you will not provide personal information about any other individual without that person’s permission.
Date: / Insured / Authorized person:
(name) / (signature)